ANEXO III

INSTRUO NORMATIVA N 77 /PRES/INSS, DE 21 DE JANEIRO DE 2015

FICHA DE CADASTRAMENTO
1. Identificao:
_____________________________________________________________________________
Nome da Instituio/Grupo:
_____________________________________________________________________________
_____________________________________________________________________________
Endereo:
_____________________________________________________________________________
_____________________________________________________________________________
Bairro:
_____________________________________________________________________________
Cidade: _______________________________________________________ Estado: _________
CEP: __________________________________ Telefone: ______________________________
nibus:
_____________________________________________________________________________
rgo Mantenedor:
_____________________________________________________________________________

2. Finalidade da instituio/grupo:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

3. Servios prestados/atividades:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

4. Usurio: ____________________________________________________________________
Faixa etria: ___________________________________________________________________
Forma de pagamento: ____________________________________________________________
Horrio de atendimento ao usurio: _________________________________________________
rea de abrangncia:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Documentao exigida:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

5. Outros dados complementares:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

6. Representante legal da instituio/grupo:

Nome: ________________________________________________________________________
Cargo: ________________________________________________________________________

7. Responsvel pelas informaes:

Nome: ________________________________________________________________________
Cargo: ________________________________________________________________________
Data: _____________________________